Provider Demographics
NPI:1548339310
Name:GREG A. NESTEBY
Entity type:Organization
Organization Name:GREG A. NESTEBY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:NESTEBY
Authorized Official - Suffix:
Authorized Official - Credentials:LO, BOC, ABC
Authorized Official - Phone:806-792-6193
Mailing Address - Street 1:4433 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-2416
Mailing Address - Country:US
Mailing Address - Phone:806-792-6193
Mailing Address - Fax:806-792-2863
Practice Address - Street 1:4433 34TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-2416
Practice Address - Country:US
Practice Address - Phone:806-792-6193
Practice Address - Fax:806-792-2863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222Z00000X ORTHO 377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX087031301Medicaid
TX102339100OtherFIRST CARE
TX513125OtherNM BCBS
NM087031301Medicaid
TX513125OtherTX BCBS
TX0614640001Medicare NSC